Community Acceptance of Services and Effectiveness of Health Camps in High-risk Areas of Karachi, Sindh, Pakistan, 2021

"To enhance immunization coverage, there is a need for interventions that focus on community engagement and the provision of basic health services."

Vaccine hesitancy to oral polio vaccine (OPV) and routine immunisation, insecurity, malnutrition, and poor access to maternal and child health care services, routine immunisation services, and water and sanitation services contribute to the remaining pockets of poliovirus circulation across high-risk areas of Pakistan. Health camps are organised to provide basic health services in underprivileged communities and to improve polio vaccine acceptability and reach among children who were missed during polio supplementary immunisation activities (SIAs). In 2021, the Emergency Operations Center (EOC) team organised health camps during the sub-national immunisation days (SNIDs) and subsequent SIAs to provide integrated health services delivery to the highest-risk communities in Karachi, Sindh province. This study was conducted to determine community acceptance and effectiveness of these health camps.

In June and August 2021, health camps were organised in eight high-risk union councils (HRUCs) of four districts of Karachi, Sindh; in October, the scope was extended to 33 UCs. All health camps provided basic health services, maternal and child health services, and routine immunisation. The health camp implementation teams collaborated with the polio programme, which provided social mobilisers to support the health camps. These social mobilisers moved from house to provide caregivers with clear directions for the locations of health campsites and services offered. Mosque announcements, banner placements in catchment areas, and megaphone announcements were also part of social mobilisation activities.

The providers delivering services at health camps included male doctors, female doctors, lady health workers (LHWs), vaccinators, dispensers, and social mobilisers. Steps were taken to ensure staff members, especially social mobilisers, had the same ethnic and linguistic profile as the community reached by the health camps. District health officers provided furniture such as tents, chairs, and tables for the health camps, engaged philanthropists and community-based organisations, arranged medicines, and provided logistical support. The select health camps that offered nutrition components included nutrition corners through an accelerated action plan programme for nutrition. The district administration team and polio programme partner staff provided support and monitored health camps.

A cross-sectional survey was carried out in three rounds after a polio vaccination campaign in June (877 respondents), August (367 respondens), and October 2021 (383 respondents). The survey was designed to gain insight into the number and type of beneficiaries (children, male, female), the type of services availed/preferred (vaccination, nutrition, consultation, medicines), and demand for other services (medical doctors, hospitals, vaccination centres, schools, safe drinking water, waste disposal, roads, etc.), as this information can be useful in planning impactful health camps in future rounds and enhance the reputation of the polio programme in the community. The main purpose of the survey was to determine community acceptance and effectiveness of the health camps. It also aimed to identify community perceptions regarding hesitancy of vaccination through polio teams. Furthermore, the assessment was designed to inform possible interventions to enhance acceptance of polio vaccination in underserved communities.

The survey revealed that female caregivers were the main beneficiaries of the camps, ranging from 698 (79.6%) in June to 300 (81.7%) in August and 317 (82.8%) in the October round. The main services availed include consultation with a doctor (64% in June, 79% in August, 78% in October), followed by childhood vaccination (58% in June, 55% in August, 69% in October) and nutrition support (34% in June, 17% in August, 17% in October).

During three rounds of health camps, more than 80% of participants who did not take their children to the nearest health facility for routine immunisation agreed to have their children vaccinated at health camps. Among those parents who do not allow their children to receive OPV from polio teams at their doorstep, 48 (81.4%) vaccinated children at the health camps in June, eight (80.0%) vaccinated their children in August, and 13 (86.7%) did so in October. Although not statistically significant, these results show that these parents may not accept polio drops in their homes due to mistrust of the quality of vaccines, fear of side effects, and negative social media videos about polio vaccines - but they were willing to vaccinate their children during health camps. So it means they do not necessarily have an issue with vaccines or vaccination but with repeated visits to their homes by polio teams.

The proportion of missed children attending the health camps who received immunisation services increased from 439 (80.3%) in June to 252 (85.7%) in August and 308 (96.0%) in October health camp rounds. Routine immunisation utilisation at the nearest health facility also increased from 647 (84.2%) in June to 289 (88.4%) in August and 318 (92.4%) in October. 

UC-level analysis shows a cumulative 14.5% reduction in persistently missed children (PMCs) in June 2021 SNIDs as compared to the March 2021 NIDs in all super-high-risk UCs (SHRUCs). Similarly, zero-dose children decreased by 4.6% during June 2021 SNIDs as compared to March 2021 NIDs in SHRUCs. Results also indicate a 10.3% reduction in PMCs in June SNIDs as compared to March NIDs in areas with health camps. Overall, from a total of 55 areas where health camps were organised during June SNIDs, still missed children who were not available at the time of the campaign reduced in 8 (14.5%) areas, still refusal reduced in 25 (45.5%) areas, and total still missed children reduced in 8 (14.5%) areas.

Some other findings:
 

• Almost all participants reported that health camps were feasible, acceptable, and useful and should be organised again.
• Health camps "played a crucial role in improving the reputation of the polio program and establishing trust among underserved communities in Karachi's high-risk areas."
• "They provided a unique opportunity for direct engagement with the community, particularly with female household members...This interaction allowed for a deeper understanding of the challenges faced in seeking healthcare for mothers and children. Additionally, it was an avenue to identify core social needs and required services in these areas..."

In conclusion: "Despite polio vaccine hesitancy in high-risk communities of Karachi, the positive collective impact of community mobilization and the delivery of maternal and child health services and immunizations through health camps during and after supplementary immunization activities was evident."